Update on Allergy, Asthma and Sinusitis

W. S. Tichenor, M. D.New York, New York

The following is selected information from various meetings which I have found interesting, important or provocative. It is not meant to be a comprehensive update.

Update on the 2002 American College of Allergy, Asthma, and Immunology Meeting in San Antonio

Zauli, et. al. presented a paper suggesting that H. pylori may play a role in chronic urticaria.

Popov, et. al. presented a poster suggesting that a new topical decongestant preparation in which oxymetazoline is mixed with a special adhesive compound may be more effective and not cause rebound.

Several papers were presented on the safe use of Pulmicort in pregnancy.

There was supposed to be a poster presented by Tanner, et. al. on the use of intravenous antibiotics in sinusitis, however, the poster was not presented. I was disappointed not to be able to question the authors because the paper did not reveal a benefit, which is contrary to several other recent papers.

Two papers were presented suggesting that the Rinoflow may be helpful for irrigation in patients with rhinitis and sinusitis.

Wagenmann found that patients with prior sinus surgery contained significantly more IL-4, IL-5 and IgE than patients without prior surgery. Similar results were found with patients with polyps.
Production of cytokines in surgical specimens correlated with symptoms
prior to surgery. Patients requiring steroids also showed higher levels.

Fahrenholz et. al. found that sinusitis patients who were not aspirin sensitive had an improvement in symptom scores after treatment with aspirin.

Fintelmann et. al. found that montelukast improved quality of life in patients with nasal polyps.

Shah et. al. found that patients preferred Rhinocort Aqua over Flonase because of sensory attributes including smell.

Leong et. al. found that the COX-2 inhibitor rofecoxib is safe in patients with urticaria caused by NSAIDS.

Fernandez-Melendez et. al. found similar results in patients with anaphylaxis.

Inoue et. al. from the Mayo Clinic reported that the fungus Alternaria activates eosinophils through EDN (eosinophil-derived neurotoxin). This may play an important role in allergic disease including asthma and chronic sinusitis.

Demera et. al. reported that out of 403 food allergic subjects, 44 reported a reaction on an airplane including 4 with life-threatening reactions, most commonly to peanuts.

Daulat et. al. reported 605 out of 606 patients with previous non-life threatening penicillin reactions tolerated cephalosporins without reaction. The one with a reaction apparently had slight worsening of her eczema.

Bergner et. al. reported several interesting findings in a group of 905 patients with sinusitis: 16% had classic migraine, 21.4 % reported olfactory triggers caused sinus pain or pressure, and 62% had positive allergy skin tests with a clinical history which was compatible with allergy.

Lardizabal et. al. reported that some food products thought to be a problem for patients with celiac disease such as vinegars and alcohol-based flavorings may actually be ok. On the other hand some food products labeled as gluten free may have detectable levels. Oat
based cereal products often had detectable levels due to handling.

Buttram et. al. reported on a patient with refractory cough who responded to Baclofen.

Kowalski et. al. reported that ASA-induced 15-HETE levels from
peripheral leukocytes may be used as an indicator of aspirin sensitivity in patients with rhinosinusitis/asthma.

Shultz et. al. reported that montelukast is useful in reducing pruritus and pain from allergen immunotherapy.

Update on the 2001 American College of Allergy, Asthma, and Immunology Meeting in Orlando

Santilli et. al. reported on fungal contamination of a school in
Connecticut causing severe symptoms in many patients in the school. It
is so bad that the school will have to be demolished. In addition to
concerns about fungal toxins causing symptoms, we are also concerned
about sensitization to molds as a result of the exposure, and also fungal sinusitis as a result of the exposures. Our experience is that there are many schools with similar problems that have not been investigated yet.

Finkle et. al. reported that there is a significant increase in injuries
due to the use of diphenhydramine (Benadryl). Older antihistamines cause more sedation than newer drugs such as Claritin.

Vacek et. al. report that the Rinoflow nasal wash system reduces asthma symptoms in patients with both rhinitis and/or sinusitis and asthma.

Rioja-Mazza et. al. reported a relationship of food allergy and ADHD.
The group only used historical controls, however. They found an
increase in RAST positivity to milk, egg white, tomato, wheat, corn,
orange, oyster, peanut and soybean.

Pongdee, et. al. from the Mayo Clinic reported success in treatment of
steroid dependent asthma with inhaled Lidocaine 2.5 cc of either a 2% or
4% solution given 2-4x/day.

Update on the 2001 American Rhinologic Meeting in Denver

Gosepath et. al. reported on the use of a YAMIK sinus catheter which
uses intermitent positive and negative pressure in the nose to evacuate
mucus. He also used 5% Betadine or 1% hydrogen peroxide.

Kingdom et. al. reported on their review of the microbiology of patients with sinusitis at the time of sinus surgery. 31 percent had a coagulase-negative Staphylococcus, which was the most predominant organism. This is important because of the common belief that it is a contaminant. This study, as well as others would suggest that it is not a contaminant.

Toffel reported on a group of 42/1600 post-surgical refractory sinusitis
patients with an increase in VCA and nuclear antigen IgG to EBV. 40/42
patients reported a decrease in recurrent rhinosinusitis with treatment
with 2 cc. of IM immune globulin every 3 months. The infection rate
went from .7/mo. to .2/mo and a 51% improvement in Quality of Life.

Anand, et. al reported that the use of IV antibiotics in selected
patients with persistent sinusitis after surgery will provide benefits
in some patients.

The Mayo clinic has increased the amount of Amphotericin they suggest in their solution for irrigation to 250 micrograms/ml.

Update on the 2001 American Academy of Allergy, Asthma, and Immunology Meeting in New Orleans

Although this study was not presented at the last meeting, I wanted to bring your attention to a recent study published in the Annals of Allergy, Asthma and Immunology by Asero et. al. in which they found that 44% of patients with nasal polyposis were found to be allergic to Candida versus 1% of atopic controls. These patients with nasal polyps did not have any of the usual allergic symptoms. There was a lesser increase in allergy to dust mites. Apparently a smaller percentage of patients with chronic sinusitis were allergic in general although no specifics were given in regard to specific allergens.

Kloos et. al. found that there is a significant increase smoking in pregnant women with asthma, and that prematurity and other perinatal disease is significantly increased.

Dunn et. al. found that patients on immunotherapy may safely continue their beta-blockers and ACE inhibitors. They did not have problems treating patients with reactions to injections, although they cautioned that ipratropium and glucagon should be available.

Visitsunthron et. al. from Thailand found that there was no effect of inhaled steroids in doses of 100-800 micrograms on the height and weight of Thai asthmatic children, however children with asthma who used nasal steroids showed a significant reduction in height and weight. This was dependent on the severity of the asthma and the age at which the steroids were started.

Allmers from Germany found that use of a special hand cream called Hand Sense TM decreased the risk of skin reactions in patients with allergy to latex who used latex gloves. This is not to imply, however, that anyone allergic to latex should use latex gloves.

Morrow et. al. found that frying and boiling peanuts will cause less allergenicity than dry roasting.

Shreffler et. al. found in vitro evidence that soy sauce is modified enough so that it may not cause allergic reactions.

Stark et. al. found that early exposure to fungi caused an increase in likelihood of
asthma. The problematical fungi were Cladosporium, Penicillium and Botrytis.

Shin and Kita from the Mayo clinic found that lymphocytes from patients with chronic rhinosinusitis produce large amounts of IL-5, IL-13, and IFN gamma. They speculated that by stimulating lymphoctyes, the fungi play an important role in sinusitis by increasing cytokines and eosinophile directed inflammation. ( See the update below for further
information on fungi and sinusitis.)

Dejama et. al. from Japan evaluated patients with chronic sinusitis and asthma. They found that those patients with a large number of mucosal eosinophiles at the time of surgery were more likely to have a poorer outcome after surgery. Although they concluded that these sinusitis patients had more impact from their asthma than perennial allergic rhinitis, they only assessed the perennial allergic rhinitis with IgE levels and RAST to dust mites. No fungi were apparently evaluated.

Borish et. al. found that patients with chronic hyperplastic sinusitis and nasal polyposis had an increasse in cysteinyl leukotrienes and suggested that leukotriene modifiers may be helpful in patients with this disease.

Sears et. al. from New Zealand found, in contrast to previous studies, that breast feeding increases the risk of asthma, dust mite sensitivity and sensitivity to any allergen.

Bernstein et. al. found that there was no effect from grapeseed extract on seasonal allergic rhinitis.

Van Cauwenberge et. al. found fluticasone nasal spray, used for a period of 50 weeks after an episode of sinusitis, reduced the number of sinusitis recurrences.

Update on the 2000 American College of Allergy, Asthma, and Immunology Meeting in Seattle

Presentations were made on the new anti-IgE drug Xolair. Although the drug was effective in treating asthma, it has been found that the medication must be given indefinitely. As a result it may not replace allergy shots a treatment for most patients. Although price has not been set yet, it is also expected that cost will also be a limiting factor in its use.

Walls, et. al. from Sydney foudn that a traditional Chinese Medicine called BIMIN was effective in treatment of allergic rhinitis.

Silvers, Ivker (publisher of Sinus Survival) and Kirkpatrick found that use of Fluconazole was helpful in treatment of chronic sinusitis patients who failed aggressive conventional treatment. Those patients first underwent Dr. Ivker's holistic treatment, but did not respond in the first 6 weeks. It was difficult to assess the holistic treatment because of the study design, but the Diflucan did appear to have some benefit.

The focus of this meeting was on the significance of fungi in patients with chronic rhinosinusitis. The most important finding was that the group from Graz, Austria, headed by Heinz Stammberger, was able to confirm all of the Mayo Clinic's finding on fungal sinusitis. They were able to show positive fungal cultures in 92 % of their patients, with an average of 3.2 organisms in each patient for a total of over 70 species. 91 % of controls also had fungi. Clusters of eosinophiles around fungi were found in 94 % of patients.

It is thought that fungi in the mucus are attacked by eosinophiles. After the attack, the eosinophiles release MBP (major basic protein) in large amounts into the mucus. MBP is toxic to the mucosa which causes damage to it and then will set up the epithelium for chronic injury. Unfortunately it is often difficult to see the fungi after it is attacked by the eosinophile because the fungi are digested. Electron microscopy shows a form of degranulation which is unique to the degranulation of the eosinophile in response to fungus. The granule forms a horseshoe shape after release of MBP.

The group from Mayo clinic presented a number of papers on fungal rhinosinusitis. The disease is now know as EFRS (eosinophilic fungal rhinosinusitis) or EMRS (eosinophilic mucinous rhinosinusitis). 43 % of patients have a positive allergy skin test for fungi or mold.

51 patients with EMRS were treated with a solution of 100 mg. of Amphotericin B in 1000 cc. of sterile water. Patients were instructed to irrigate both sides of their nose twice per day with 20 cc of the solution. Patients were treated from 3 to over 12 months. Of those, 75 % had improvement. 31% of those who improved and were on systemic steroids were able to reduce their use, and 50% were able to stop systemic steroids.

Although when given intravenously, there are serious side effects with Amphotericin B, topically it causes few problems which can include burning due to the fact that it must be mixed with sterile water. It cannot be mixed with saline, and must be protected from light and refrigerated. It is therefore very inconvenient to use. We anticipate that patients will need to be treated indefinitely, or at least until we understand better why these problems are occuring. We are working on other agents which we hope will be able to be used in the near future.

Wei from the Mayo clinic showed that eosinophilic migration from EMRS patients is increased in response to mucin extract. These were inhibited by antibodies to RANTES, eotaxin and CCR3. Migration in eosinophiles from normals was also increased (although less) in the presence of mucin from EMRS patients. Finally the migration was inhibited by mouse IgG.

McDonald from Mayo presented a paper using a stain called chitinase which is specific for fungi. With that technique using a confocal laser microscope, they were able to increase the number of fungi identified microscopically. It is hoped that the technique will be able to be used in the near future for light microscopy.

Congdon from Mayo showed that levels of MBP in mucus of patients with EMRS were 2-12 mg/ml, with all but one control having undetectable levels.

There were several discussions on the empty nose syndrome. There are still numerous workers who believe that large amounts of mucosal tissue can be safely removed from the nose without causing atrophic rhinitis. There is still no good treatment for patients who have continued symptoms with having had large amounts of turbinate tissue removed. There are currently attempts being made to replace tissue.

Baudoin presented a paper on the use of capsaicin .5 ml in a solution of 30 umol/L for patients with nasal polyps. There was a significant reduction in polyps as well as a decrease in eosinophilic infiltration.

Djupesland presented a paper suggesting that nonpathogenic fungi in nasal mucin may play a protective role by inducing NO production , whereas mutations of the same genus may damage mucosa by not producing NO.

Obando presented a paper on the use of a robotic arm in surgery which is helpful under the circumstances when we could all use a third hand.

Wolfgang Mann presented a paper on rapid Aspirin desensitization using a 2 day regimen.

Update on the 2000 American Academy of Allergy, Asthma, and Immunology Meeting in San Diego

Leitner et. al. found that 2 years of venom immunotherapy may be enough.

Johnson et al. found that pet ownership in the first year of infancy may decrease the risk of later childhood allergies, but another paper found that cat exposure in the first two years of life increases the risk of later severe asthma.

Lopez-Gonzalez, et. al. reported that a few patients with ulcerative colitis had complete loss of symptoms upon elimination of skin test positive foods including milk, peanut, potato, orange, tomato, wheat, rice, and fish.

Souza-Machado et. al. found that approximately 50% of patients with moderate to severe asthma did not perceive the degree of obstruction, enforcing the need for objective measures.

Wydila et. al. found that 65% of college swimmers showed asthma or exercise induced bronchospasm.

Klossek et. al. found no effect on mucociliary fundction in patients treated with Nasacort.

Neto et. al. found that IVIG can be given subcutaneously which would save a large amount of money.

Asero et. al. found that 70% of patients with urticaria were reactive with autologous serum

Hu et. al. found that a Chinese herb called BIMIN was effective in perennial allergic rhinitis in a randomized double-blind placebo-controlled trial. This was the first good trial showing efficacy of an herbal mediation in rhinitis according to the authors.

Anti-IgE update

An article appeared in the New England of Medicine on December 23, 1999 on the use of an injectable drug called rhuMAb-E25 which blocks the action of IgE. The drug was used to treat asthmatics and was found to decrease the use of steroids.

Although there was a lot of press on this drug, it is only in Phase II clinical trials. I have a lot of concerns about the usefulness of the drug. It must be injected, and it blocks IgE completely ( we don't fully know what IgE does: we do know that it causes allergies and is used to fight parasitic infections). The study did not include patients on Flovent (I assume because it wasn't released yet). Because Flovent is so potent, it may allow patients to discontinue oral steroids when they previously would not have been able to do so.

Since most allergists have very few, if any, patients on oral steroids, I was surprised that the researchers were able to get so many steroid dependent patients into the trial. I am concerned that many of the patients may not have been treated optimally prior to the study. Indeed, the researchers noted that many patients got better after being treated just due to good allergy management.

Update on the 1999 American College of Allergy, Asthma, and Immunology Meeting in Chicago

A study by Dr. John Santilli, Co-chair of the Sinusitis Committee suggests that there may be a relationship between the Hepatitis vaccine and worsening of allergy and sinusitis symptoms. In addition there is a lowering of IgG-3 levels in those patients.

The makers of Ocean are suggesting using Singulair dissolved in Ocean and sprayed in the nose as a treatment for nasal polyps.

Dr. Sverre K. Steinsvag from Norway presented some very convincing material that suggests that benzalkonium chloride, which is a preservative in most nasal sprays including all current AQ formulations, may cause severe damage to the lining of the nose including loss of cilia. The effects on the sinuses are unknown. Rhinocort will be coming out with a new AQ formulation which does not have benzalkonium chloride. It is also contained in Ocean and Ayr.

Raxar has been recalled due to effects on the heart.

Two studies were done suggesting that Nasonex and Flonase are helpful in treatment of sinusitis.

A study done by Dr. J.L. Counts using a new product called the Swiffer, which is a disposable cloth which attracts dust, is helpful in removing dust mites. It is available from most stores carrying cleaning products.

A study done by Dr. M.L. Loren suggests that symptoms from a sinus headache commonly overlaps with those of migraines and allergies.

A new website entitled eMD will be opening soon. Look for general information, and pharmacy services as well as many other helpful items for patients and physicians.

Update on the 1999 American Academy of Allergy, Asthma, and Immunology Meeting in Orlando

A study in Finland by Kilpelainen, suggested that stress could affect immune system function as well as allergic disease.

A study by Melen in Sweden suggested that exposure to cats during the first two years of life creates an increased likelihood of sensitization to either cats or dogs later in life.

A study by Sheikh from Los Angeles, suggested that there is a significant association between H.pylori and chronic urticaria. Another study suggested that Hydroxychloroquine may be helpful in treatment of chronic urticaria. A study by Saadeh from Amarillo, suggested that weekly Methotrexate may also be helpful. Other suggestions included the use of cyclosporine for refractory cases

An investigational study by Hochhaus from Gainsville, Florida, suggested that a novel delivery system called the 'Spiros' may be helpful for delivery of inhalers. The spiros is delivery system for dry powder inhalers.

A study by Jamie Lee from the Mayo clinic in Scottsdale, on the use of P-Selectin Glycoprotein Ligand-1 in mice shows great potential and suggests that blockage of P-Selectin may offer excellent potential in treatment of allergic disease. We await human studies.

A study by Miller from Danbury, CT suggests that moth balls will kill dust mites in wool clothing.

A study by Platts-Mills from the University of Virginia, suggests that coagulase negative staph may produce chronic sinusitis as a result of productions of superantigens to which the patient can develop an allergy.

Several "Dear Doctor" letters have been sent recently suggesting that Flovent metered dose inhalers and Singulair may both be associated with some symptoms which occur in Churg-Strauss syndrome. It has been suggested by many workers that this is actually an unmasking of the disease as a result of reduction in oral steroids and does not clearly represent new disease.

The shortage of intravenous immunoglobulin continues and it is not anticipated that there will be an improvement in the supply until much later this year .

There were several studies suggesting that tacrolimus as a topical treatment for atopic dermatitis may be helpful. It is hoped that later this year it will be released for that purpose by the FDA. It is currently available for other indications.

A case was recently reported by Finkel et al from Denver of a patient treated with Accolate who developed Lupus. The frequency of this phenomenon is unknown as of yet.

A report by Svanes from Norway suggests that sharing bedrooms, the presence of a dog in childhood and subjects from families which were large will all reduce the likely of allergies as one grows older.

Update on the 1998 American College of Asthma, Allergy, and Immunology Meeting in Philadelphia

It appears that the problems which manufacturers have had supplying adequate amounts of allergy extracts should be ending soon as the FDA completes it's evaluation process.

In a study reported by
Alejandro Ortigas, M.D., four of five patients with antibody deficiencies being treated with intravenous immunoglobulin were able to discontinue the IVIG replacement after periods of time ranging from 6 months to five years. All of the patients had adequate responses to 7 of 9 Pneumococcal serotypes after immunization with pneumovax.

Interferon Alpha was used to treat patients with angioedema in a study by Adela Taylor.

In a paper reported by Michael Klovsky, roadside dust contained evidence of mold, weeds, tress, grasses, and animal dander. Twenty-three percent of patients who were atopic were found to be allergic to the dust.

Several reports suggest that rare patients treated with high doses of Fluticasone may develop adrenal suppression.

Update on the 1998 American Academy of Allergy, Asthma, and Immunology Meeting in Washington, D.C.

A poster by Dr. E. Tovey from Sydney,Australia suggested that a new test may be able to determine which allergens going into your nose cause your individual symptoms.

Even though you may get rid of all the cockroaches in your house, unfortunately, it doesn't mean that all of the allergen is gone. Dr. L.W. Williams from Duke found that it continued to appear in vacuumed samples for at least 6 months.

A paper by K.C. Bergeron from Vanderbilt found that treatment of sinusitis often helps urticaria. Other papers suggest that leukotriene inhibitors/antagonists may help urticaria and sinusitis.

Good news for latex allergy suffers: Dr. G. Toci from Thomas Jefferson in Philadelphia found that an oral desensitization regimen may be helpful

A very interesting study by Dr. F. Lavigne from Montreal found that patients with IL-5 mRNA expression which is increased may not respond to sinus surgery.

Dr. S.W. Huang from the University of Florida at Gainesville found that patients with an increase in protein (over 1.5 by Ames dipstick) in the mucus and a pH over 7.25 were more likely to have sinusitis.

You should see a number of articles in the near future about using your allergist for treatment of sinusitis.

A recent article was written by Dr. D. Hahn about the importance of Chlamydia pneumonia in asthma, including the treatment with antibiotics. It appeared in the January, 1998 issue of the Annals of Allergy, Asthma and Immunology

Update on the 1997 American College of Asthma, Allergy, and Immunology Meeting

SinuCare is a company which was started to provide intravenous antibiotics on an outpatient basis to patients with chronic sinusitis who have not responded to other forms of therapy. It is possible that this may be used as an alternative for surgery, or in patients who have not responded previously to surgery. Their internet address is http://www.sinucare.com.

Integrated Infusion Services is a company that helps establish intravenous gammaglobulin infusions at doctors' offices. They will help with problems with insurance companies who often will deny payment. They are on the internet at http://www.infuseonline.com.

The Allergy Solution, Inc., provides allergy supplies at low cost. Product sales support a non-profit allergy health agency. They can be reached at http://www.allergysolution.com.

It is currently estimated that approximately 12 million americans have asthma and spend approximately 6.2 billion dollars a year. It has now been shown that specialist care by allergists can significantly reduce the morbidity and mortality of asthma.

A report suggested that fatal and near fatal asthma is related to two features: rapid evolution of the event, and a past history of intubation.

It was found that patients with allergic fungal sinusitis often have the same fungi which are found in their sinuses also growing in their homes. It was also found that they had exacerbating environmental factors. An increase in shade, evidence of moisture, crawl spaces, and poor environmental controls all can contribute. Common molds included cladosporium, epicoccus, alternaria, as well as aspergillus, aureobasidium, curvularia, penicillium, and trichoderma.

Several patients who had resistant urticaria were found to have significant relief with zafirlukast (Accolate).

A new treatment for chronic fatigue syndrome with NADH by Joseph Bellanti, M.D., showed that 73% of patients in an open label study showed significant improvement in symptoms. It is available under the brand name ENADA. They maintain a web site at http://www.menuco.com. They are also at 1-800-MENUCO-1.

Patients who have been started on Pulmicort should be assured that any shortage of medication in pharmacies is temporary and that you should be able to obtain it through your allergist.

There is now available a test to quantitate the number of dust mites in your house dust. It is available through many of the allergy distributors, which you will see on the bookmark section. You can also send an email to:allergy.labs@worldnet.att.net.

Update on the 1997 American Academy of Allergy, Asthma, and Immunology Meeting in San Francisco

The most important recent development was the release of the "Guidelines
for the Diagnosis and Management of Asthma", which was released at the
American Academy of Allergy, Asthma, and Immunology annual meeting in San
Francisco on February 24, 1997.

The guidelines were originally developed in 1991 to allow dissemination of
information on management of asthma, sponsored by the National Heart,
Lung and Blood Institutes (NHLBI), National Asthma Education and Prevention
Program (NAEPP). The full text of the report is available on the internet
at: http://www.nhlbi.nih.gov/nhlbi/nhlbi.htm or from

The importance of inflammation as it contributes to asthma has become better
recognized over the past six years. The importance of "sub-basement
membrane fibrosis" has become clearer in regard to persistent changes in
lung function.

Classification of disease has been changed from mild, moderate and severe
to: mild intermittent, mild persistent, moderate persistent, and severe
persistent, in order to recognize the variability in disease.

Peak flow monitoring suggestions have been changed so that generally morning peak flows are suggested. If the morning reading is less than 80% of
the personal best it may be worthwhile to do more frequent monitoring.

Allergy testing is now specifically recommended for patients with persistent
asthma. Importance of concurrent treatment of allergy problems to
reduce asthma severity is also emphasized. Aspirin avoidance should be used
in patients with sensitivity to NSAIDS. Chemical agents to kill dust
mites are no longer recommended. Annual influenza vaccines are suggested
for patients with persistent asthma.

Medications are now classified under "long-term control" and "quick-relief"
The importance of newer medications including Serevent, Tilade, Accolate
and Zyflo are included in the therapeutic armamentarium.

The stepwise approach to asthma therapy was maintained but it was suggest
ed that higher initial doses of medication be used with a stepdown approach, reducing medication dosage as patients improve.

There is a new section on asthma in infants and young children based on more recent studies.

An overview of the guidelines suggest that patients with mild intermittent
asthma typically will have symptoms less than two times a week and can
typically be managed with Step 1 therapy with inhaled short-term beta agonists

Patients with mild persistent asthma typically have symptoms over twice a
week but less than once a day, and can be treated with Step 2 care with
inhaled beta agonists along with anti-inflammatory drugs (including inhaled corticosteroids, Intal, Tilade, Accolate, or Zyflo).

Patients who have moderate persistent asthma have daily symptoms and require
Step 3 care with daily use of a short-term beta agonist. They may be
managed with inhaled corticosteroids, a long acting beta agonist and oral
corticosteroids as needed.

Severe persistent asthma patients will typically have continual symptoms,
frequent exacerbations, and an FEV-1 of less than 60 % with frequent
nighttime symptoms. With Step 4 care, in addition to the above agents, they
may also need sustained release theophylline and oral corticosteroids.
It is also emphasized in the guidelines that patient education is critical.

Other important information at the allergy meeting include the release of
a new antihistamine nasal spray, Astelin. This has the advantage of localizing
antihistamine effects to the nose, however there may be more of a
risk of sedation than with the newer second generation antihistamines.

A new inhaler called Combivent combining albuterol and atrovent will also
be released in the near future.

A new eye drop has been released which combines both antihistamine and
mast cell stabilizing agents in a single eye drop, called Patanol.

Abstracts were presented suggesting that Echinacea, Quercetin, and Chines
e herbs (Sho-seiryu-to and Ryo-kan-kyo-mi-shin-ge-nin-to) may have antiallergic
effects.

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